GHS Outpatient Enoxaparin Program Rondell Jaggers, PharmD Grady Health System Atlanta, Georgia

Grady Health System Core Mission: Care for the medically underserved

Pharmacy & Drug Information 11 Outpatient Prescription Pharmacies Inpatient Pharmacy + four satellites Clinical Pharmacy Services Pharmacy Administrative & Support Services Pharmacy residency program PGY1 PGY2 (Internal medicine, infectious diseases, critical care, oncology, and emergency medicine)

Objectives Describe GHS Pharmacy Services outpatient enoxaparin program Explain the process for initial assessment and follow up in clinics Discuss staffing model Describe the program’s impact on hospital admissions and length of stay (LOS)

Outpatient Enoxaparin Program Initiated in 2006 Developed and managed by clinical pharmacy staff and pharmacy residents Program goals Safe and efficient process to bridge patients to warfarin and facilitate hospital discharge (or avoid admissions)

Process Consultation Financial criteria met? Financial counseling No Financial criteria met? Yes Yes Financial counseling Contraindications? No Continue Heparin Consult Service Assessment Inclusion/exclusion criteria Financial status Education Discharge Oupatient follow-up Referral to Coumadin Clinic Institutional practices Physician preference Suggestion: in last row of flow diagram, the middle box, include name of clinic, “Outpatient f/u in Lovenox clinic, therapeutic?” Enroll in Enoxaparin Program Reschedule follow-up visit No Outpatient Follow-up, therapeutic? Yes Referral to Coumadin Clinic

Inpatient Assessment

Inclusion Criteria Deep vein thrombosis Established warfarin patient requiring temporary discontinuation of warfarin Subtherapeutic INR Atrial fibrillation Coagulopathies

Exclusion Criteria Not willing to self-inject Active or high risk of bleeding Obesity (>150 kg) Unstable PE Liver disease HD dependent History of HIT or hemorrhagic stroke Unable to return for follow-up visit Noncompliance Financial constraints

Exclusion from Outpatient Program Pregnancy Coagulopathies Prophylaxis Orthopedics Surgery Hematology/Oncology Infectious Diseases Ponce Clinic

Education Indication Mechanism of action Dosing Administration Adverse effects Drug-drug and drug-food interactions Storage of syringes

Discharge Dosing Approval of patient self-injection technique Pharmacist co-signature Progress note Outpatient follow-up appointment

Outpatient Follow-up Assessment Reschedule or referral Compliance Monitoring of INR Worsening symptoms New onset VTE or PE Adverse effects Medications Diet Reschedule or referral

Number of Patients Evaluated Monthly 1/1/2008 – 7/31/2008

Indications for Therapy *stroke, protein C deficiency, anti-phospholipid syndrome, and cancer prophylaxis

Outpatient Enoxaprin Program Patients screened N = 109 Patients not receiving enoxaparin n = 15 Patients receiving enoxaparin n = 94 Patients requiring PharmD follow-up n = 83 Patients not requiring PharmD follow-up n = 11

Follow-up Total number of patients with clinic visits 63 Average number of follow-up visits/patient 2 Total number lost to follow-up 51 Average number of days from discharge to therapeutic INR 9 Average cost of enoxaparin therapy* (based on 90-mg dose) $810 / patient Total cost of enoxaparin therapy† $51,030 * Average cost per day = (180 mg/day) x (1 ml/100 mg) x ($0.50/mg) x 9 days = $810/patient † Total cost of enoxaparin therapy = $810/patient x 63 patients = $51,030

Outpatient Enoxaparin Program Hospital Admissions and Length of Stay Not included in Program (n = 26) Included in Program (n = 83) Average LOS (days) 13 5 Average LOS after date of screening (days) 2 0.5 Patients who were admitted (%) 93 81

Outpatient Enoxaparin Program Hospital Readmission Rates Not included in Program (n = 26) Included in Program (n = 83) Patients readmitted after screening date (%) 35 28 Average time in days to readmission 23 57

Conclusions 389 hospital days were spared by initiating enoxaparin therapy Cost savings during the 6-month period were ~$389,000 Estimated savings for one year is $778,000

Number of Patients Evaluated Monthly 1/1/2008 – 7/31/2008 and 1/1/2009 – 4/30/2009

Outpatient Enoxaparin Program Promotes safe anticoagulation management practices Results in cost avoidance Decrease LOS Avoid admissions Access to patient assistance program Facilitates training of pharmacy residents